Many patients with type 2 diabetes who rely on Medicaid face significant barriers when trying to access life-saving medications. A comprehensive analysis published in the Annals of Internal Medicine reveals that approximately 25% of Medicaid enrollees have restricted access to sodium-glucose cotransporter 2 (SGLT2) inhibitors, while a staggering 40% face limitations accessing glucagon-like peptide-1 (GLP-1) receptor agonists.
Critical Medications Remain Out of Reach
Among the estimated 6.8 million diabetes patients enrolled in Medicaid programs nationwide, a substantial portion cannot easily obtain medications proven to reduce cardiovascular events and mortality. Lead investigator Dr. Anil Makam from the University of California, San Francisco highlights the significance of these medications: “These are the first two classes of medications that I would say convincingly, and in replicated randomized, controlled trials, have demonstrated reductions in cardiovascular events and mortality [in patients with diabetes].”
The research represents an important step in addressing what Makam calls the “evidence-translation gap” – the challenge of moving proven treatments from clinical trials into everyday medical practice. While adoption of new therapies typically takes time, these particular medications face additional barriers. As Makam explains, “You can’t prescribe it if it’s not available, or at least if it’s available, with a lot of hoops and hurdles as we’re describing here.”
Proven Cardiovascular Benefits Being Overlooked
The cardiovascular benefits of these medications have been well-established for years. Empagliflozin (Jardiance), an SGLT2 inhibitor, demonstrated significant reductions in major cardiovascular events and mortality in the EMPA-REG OUTCOME trial a decade ago. Similarly, GLP-1 receptor agonists have shown impressive results in reducing cardiovascular and renal events, along with mortality rates, in patients with diabetes who have or are at high risk for atherosclerotic cardiovascular disease (ASCVD).
Both drug classes have earned strong recommendations from major medical organizations. The American Diabetes Association, American College of Cardiology, and European Society of Cardiology all endorse these medications for patients with type 2 diabetes. In European guidelines, both classes receive class 1 indications for patients with type 2 diabetes who also have ASCVD, chronic kidney disease, heart failure, or high ASCVD risk.
Despite these endorsements, both SGLT2 inhibitors and GLP-1 receptor agonists remain underutilized in eligible patients. Their high costs are frequently cited as the primary barrier to more widespread use.
“These drugs are now considered first-line therapy for many individuals with diabetes,” Makam emphasizes. “It’s not a minority of people.”
Geographic Disparities in Medication Access
The research team conducted a cross-sectional analysis of Medicaid formularies across all 50 US states, Washington DC, and managed care organization plans covering 39 states. They assessed whether patients had unrestricted access (defined as not requiring prior authorization or step therapy) to at least one medication from each class.
The results revealed significant geographic variation in access. Among fee-for-service plans, 40 states included at least one SGLT2 inhibitor on their preferred drug list, while only 30 states included a GLP-1 receptor agonist. Just 29 states provided access to both types of medications. Notably, tirzepatide (Zepbound), a powerful dual GIP/GLP-1 receptor agonist, was available in only one state.
For the 273 Medicaid managed care organizations examined, 66.7% offered an SGLT2 inhibitor, and only 48% included a GLP-1 receptor agonist. Less than half (47.3%) provided access to both medication classes. Prior authorization emerged as the most common restriction, required by approximately 60% of plans. Additionally, 10% of plans implemented step therapy, requiring patients to try alternative medications before approving these more effective options.
“Depending on what state and what plan [you’re in]—you can be in the same state and under a different managed care organization—you can have variable access to these medications,” Makam notes.
Counterproductive Cost-Control Measures
The researchers found that dipeptidyl peptidase-4 (DPP-4) inhibitors, considered second-line agents, were much more widely available, appearing on the preferred drug lists of 42 states and accessible through nearly 75% of managed care plans. This discrepancy raises important questions about formulary decision-making.
Makam argues that placing step-up restrictions on SGLT2 inhibitors and GLP-1 receptor agonists is counterproductive when considering their proven cardiovascular benefits. Unlike traditional diabetes treatments focused solely on glycemic control, these medications significantly reduce ASCVD events. Furthermore, major clinical trials have demonstrated that these benefits appear relatively quickly.
“These are short time horizons to benefit,” explains Makam. “Unlike intensive glycemic control, which takes 10 to 20 years to realize any meaningful benefit, this is in the order of months, and absolute benefits will accrue over time.”
Rethinking Medication Access Strategies
The research team suggests that Medicaid programs should reconsider their approach to medication access. Despite DPP-4 inhibitors being costly medications, they remain more widely available than SGLT2 inhibitors and GLP-1 receptor agonists. While excellent for glycemic control, there are many less expensive alternatives to DPP-4 inhibitors.
“Given the unique evidence—the benefits of reducing cardiovascular disease—and that constraining pharmaceutical cost is a high priority for plans, switching restrictive coverage to DPP-4 medications and making the SGLT2 and GLP-1 medications more available might offset some of those added costs,” Makam suggests.
The researcher notes that while these drugs may not be cost-effective at current market prices, significant Medicaid drug rebates bring their actual cost down considerably. These rebates push the medications closer to acceptable cost-effectiveness thresholds, potentially making broader access more feasible.
For millions of vulnerable diabetes patients relying on Medicaid, improving access to these life-saving medications could significantly reduce cardiovascular events and extend lives. As healthcare systems continue to emphasize evidence-based medicine, aligning medication access policies with clinical evidence represents an important opportunity to improve patient outcomes.
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